Youth Center for Excellence

DYNAMIC WORKS

SUMMER REGISTRATION FORM

Thank you for your interest in our summer program! Here are some helpful FAQs:

About: This summer, we will be diving into all things entreprenuership. Through this creative avenue, students will learn a variety of skills that will enhance thier way of thinking about the world as well as themselves, pushing them toward future success. As a part of our program, students will also be receiving professional media and tech training from Another Wave Media team.

Lunch will be provided daily and students will attend a field trip each week.

Dates: The program runs every Monday - Thursday from June 9 - July 31, 2025

Program hours: 10am - 3pm

Population: This summer we are serving students ages 14-18

Registration Fee: $50 (one time fee)

Weekly Pricing: $395/week (including transportation)
Student's Name*
Nickname (if applicable)
Date of Birth*

MonthDayYear
Date
Sex*

MaleFemale
Race

White/CaucasianBlack/African-AmericanHispanicAsianAmerican IndianMullti-racialOther
What is the student's primary language?*

EnglishSpanishOther
Is the student approved for this program through FAPT? **Please note that FAPT approval is mandatory for enrollment.*

YesNo
Home Address*
Current School*
Grade*
Photo & Media Release*

Yes, I give permission for my student's images to be used in videos or photos that may be used in program materials, promotional materials, social media, etc.No, my student's image may not be used in Dynamic Works images or videos.
PARENT(S)/GUARDIAN(S)
Guardian 1*
Home Phone*
Format: (000) 000-0000.
Email Address*
example@example.com
Home Address*
Place Employed
Business Phone
Format: (000) 000-0000.
Guardian 2
Home Phone
Format: (000) 000-0000.
Email Address
example@example.com
Home Address
Place Employed
Business Phone
Format: (000) 000-0000.
Agency Having Legal Custody of Child (if applicable)
Agency Address
Agency Representative's Email Address (ex. Social Worker, etc.)*
example@example.com
Phone
Format: (000) 000-0000.
EMERGENCY INFORMATION
Please list two emergency contacts in the event that a parent/legal gaurdian cannot be reached
Person 1 - Authorized To Pick Up Child*
Phone*
Format: (000) 000-0000.
Address
Person 2 - Authorized To Pick Up Child*
Phone*
Format: (000) 000-0000.
Address
Person(s) NOT Authorized To Pick Up Child (if applicable)
MEDICAL INFORMATION
Child's Physician
Health Insurance Carrier
Policy Number
Does the student have any medical diagnoses or conditions (including mental health diagnoses)? If so, please list.
Does the student have any known allergies or food intolerances? If so, please list.
Is the student currently on any medications? If so, please list.
Does the student have any behavioral concerns of which we should be made aware? If yes, please explain.
Supporting Documents: If applicable, attach any ISFP, IEP, 504 plan, or psychological evaluations. Please note, all documents are kept confidential per Dynamic Works policies.

Cancelof
I certify that all information on this form is complete and true.*

Yes, I certify.
Signature*
Should be Empty:

PARENT(S)/GUARDIAN(S)

EMERGENCY INFORMATION

MEDICAL INFORMATION